RN vs. LPN scope conflict: what would you do?

[LuxCalidaNP]

Hi all,

I recently started working at a large community health center that is a wonderful home to 5 nurses, myself included. 2 of these nurses are seasoned LVNs, with lots of experience in elder care, wound care, and immunization clinics.

I was recently charged with restructuring our nursing model to create more patient contact and assessment, start a nurse-led admissions clinics, and maximize our scopes of practice! very exciting!

However...

As I assessed the interests of our nurses, the LVNs "definetely want to assess more, do more patient education, and triage!" ruh... roh.....

No one, in the 25 years one of them has been at this clinic, has bothered to check LVN scope of practice, and has been letting them determine normals and abnormals, assess patients and plan care, provide education, and do phone triage (without any written policy). They have had no RN "supervising," nor do they run these assessments by providers.

By my research (nursing practice act and info from BOTH boards of nursing), this is beyond the scope of the LVN in California, and puts the RNs in their clinic on the line for not adequately supervising or delegating.

So...What woudl you do?! would you challenge their "old seasoned" way of doing things? tell management? I am in the position of having to tell them that they can't legally assess and plan care in a nurse-led admission clinic. I am stuck! As a person who hates raising stinks, it might be the only thing that management takes seriously.

Feedback welcome!

Thanks!

[traumaRUs, MSN, APRN]

I would take this knowledge to the management team and see how they would like to handle it.

[diprifan]

They know their scope of practice. As an LVN they need to function within their role, no matter their years of experience. I would not discredit their skills.

[nurseygrrl, LPN]

I am an LPN and in my facility, management sometimes forgets that we are governed by our scope of practice, not our bosses. They like to ask us to do a lot of things beyond our scope. I think it's important to let these nurses know that while you are sure they are and have been more than capable of these tasks, for the protection of your license and their licenses things will have to change. Better you tell them than the BON.

[kakamegamama]

Follow the BON scopes of practice for LPN/RN with anything you do, whether it is writing the policies (that's challenging and actually quite informative and you sound like just the person for this--your enthusiasm shows), or whatever. If you are the RN working with a LPN who practices out of her scope of practice, what will happen to YOUR license?

[NurseLoveJoy88, ASN, RN]

Always follow the board or nursing and nurse practice acts. This is the only way.

[diprifan]

Following the BON is not the only way... it is the only correct way.

To the OP:

Make the plan, submit it to management, and rustle a few feathers of the "old seasoned" nurses. And yes you are in the position to tell the LVN's not to assess and admit... because you are the RN and that is beyond their scope of practice.

You're just protecting both licenses.

[Woodenpug, BSN]

You do not need to risk anyone's license or ruffle any feathers. The BVNPT allows LVN's to collect data, just not interpret that data. The LVN's can collect all of the admit information, then an RN signs-off and initiates the nursing plan of care.

I think it's funny how now I can chart "wound is healing well," when as an LVN, I had to chart "wound is beefy red, with scant, non-purulent, drainage and evidence of granulation tissue."

[P_RN, ADN, RN]

Surely on their annual vist it has come up? Staffing........x RNs, X LPNs, XCNAs. I bet they're counting management and others and not floor RNs. (Guess you could have someone anonymous call the BON and ask why therre are not any RNs working the floor?)

[backatit2]

they're probably (at least one or some of them) not comfortable doing things outside of their scope, but do it anyway bc they're also not comfortable saying NO when they're told to do something.

i'm afraid of being put in this position actually. i'll hopefully start working as a CNA soon to get some experience while i go through the BSN program. it's an 18 month program so chances are i'll know how to do a lot of things that i'm not supposed to do until i'm licensed. i've already been warned by instructors who are RNs that this happens and will likely happen so when it does to "remind" the nurses it's out of my (and fellow classmates) scope.

i would make sure to say that while you know they've been doing it and are competent/capable that it has to change for safety reasons. i don't see how they could be upset by that - i'd be relieved - not that i'd do anything out of my scope to begin with. also, from what i understand, they can ASSIST the RN so i'd make that clear also so it doesn't turn into a hostile "that's out of my scope" everytime they're asked to help do something.

[nurse2033, MSN, RN]

I would prepare a presentation comparing facility practice against the NPA. I would create suggested new policies that are in line with the law. The feelings of the employees that have been out of scope for years are not your concern, that is management's issue. Your RN would be at risk if the practice continues. Just because it hasn't come up in a lawsuit yet doesn't mean it can't. Good job and good luck.

[APRN., DNP, RN, APRN, NP]

I would immediately stop any hint of the LVN's initiating any care plans, pronto. The LVN's can contribute to the care plan. This is a number one priority.

Any admission/initial assessments need to be countersigned by the RN. "I agree with/concur with /have reviewed the LVN's assessment." - or similar wording. An additional note can be added if the RN feels additional information is needed.

Telephone triage can be tweaked where telephone messages are collected, and then "triaged" to the RN for further review until such a time when a decision tree can be decided upon and implemented. NO advice is to be given in the meantime, even if it is for something as simple sounding as a hang-nail. (Kaiser hospital uses some non-nurses for incoming calls....but they are extremely, very, highly scripted - and RN's "audit" the telephone calls intermittently.) Any deviation from the script and the call is kicked over to an RN.

These are the things that I have learned after many years of being an LVN in California and having to report to an RN, as well as many subsequent years of being an RN in California and in turn, delegating to LVN's.

Hope this helps. It may not be a pleasant experience for all involved, but ignorance of the law will not protect you, nor those who will be affected when the other shoe drops.